Epilogue 2, The Last Post

Epilogue 2, It is hard to know what to say in the end, platitudes and gratitude are the staple of goodbye speeches, but I think Mseleni has meant more than just superficial sentiments. I still believe that I wont really be able to fathom its affect on me for some time yet but one last time I will try and put my thoughts down.

Everyone keeps asking me about the things I will miss and it is hard to not to talk about specifics; flying to clinic, the excitement of OPD, the weekends exploring and living by the golden beaches and warm waters. I think it will also be hard not to miss feeling a part of the hospital community, getting involved with the running of the place and having a sense that what I did had a real effect on people.

Perhaps the best way to think about how I feel now is remembering how I felt in the beginning. Being so far away from home and everything familiar was always going to be a challenge and arriving in Mseleni I was cautious about how I may feel isolated. However, my good fortune meant that from the moment I arrived I was surrounded by individuals that never gave me any opportunity to dwell on the past, and instead challenged me to do more and better. I may have met these individuals as mere colleagues but I have left them as the closest of friends.

What bothers me most about leaving Mseleni is that I know that I can never again have all that I have left behind. Sure, I may be able to go back again someday but I’ll be at different place in my life, my friends would have moved on and even the place may have moved on. It will never again be the same.

Above all I will miss myself in Mseleni. Professionally and personally I became someone I’ve aspired to be in this sleepy little village in the heart of Maputaland, someone that it is not always possible to be in the metropolis of London. I keep thinking that no significant experience can leave anyone unchanged and through time I will discover how significant an experience Mseleni has truly been.

For now I will live vicariously through my memories, my pictures and my writings, remembering the hard times as not so bad and the good times as great.

http://www.youtube.com/watch?v=x38xS01NtHw

Epilogue 1, Needles, Cows and Snakes

Epilogue 1, As I begin to reflect on my time in Mseleni it is easy be rose tinted about it all, but the truth is that there are certain things I wont miss. And to be honest, there are three things that I’m amazed I managed to avoid during my stint there.

The first is a needle stick injury. In terms of practicing medicine anywhere in the world, this is always a risk. With hospitals in South Africa not being set up in the most safety conscious of manners it is not surprising that most of my colleagues had to be on courses of post exposure prophylaxis (PEP) at some point. I had anticipated that through my stay there would be at least one instance where I or someone loses concentration and a mistake is made.

The transmission rate of HIV through needle sticks does not have a lot of hard evidence and there is little real proof regarding the efficacy of PEP therapy, even so I was glad not to have contributed to the statistics. Forgetting the anguish of thinking the worst for 6 weeks, the debilitating gastric effects of the ARVS are substantial and thus I am fortunate not to have wasted any time being ill with the medications.

The second great avoidance was the cows on the road, but this was not for a lack of trying. In Zulu land cows roam freely, particularly on the roads. With no lights on the road and opposing cars flashing their brights, conditions are ripe for bovine collisions. Most of the MVAs (motor vehicle accidents) that come into the hospital have been cow related and the results vary from minor injuries to major trauma and even several deaths. When its cow versus car, I’d usually place a bet on the car to come off worse.

On a couple of occasions I came pretty close. Driving in the darkness it can be quite difficult to pick out the shape of a dark cow crossing the road. This becomes especially so after a long drive back from Durban or a late night in Sodwana. It has only been through the quick reflexes of my friends’ driving, some well maintained cars and simply dumb luck that has prevented me lying on the road like so many every day.

The third great escape is of course snakes. Locals find this a great source of amusement but I find it hard to call it an irrational fear when Mozambique Spitting Cobras, Boomslangs, and Black Mambas are common place. Though the tamer puffadders are the most common culprits, I’ve seen a multitude of patients writhing in agony from the bites and I’d rather not experience it firsthand.

The one afternoon coming down to my park home I found a slithering creature creep underneath the house. I could only really think one thing, this clearly gives credence to my ideas about keeping an army of mongoose pets. It didn’t really matter that it was probably a harmless (relatively) brown house snake, the incident was unsettling nonetheless. The important thing however, is that through a healthy combination of paranoia, diligence and a predilection for closed shoes I got away without a bite.

http://www.youtube.com/watch?v=86GQf4F8htI

Day 343, Gorillas in Uganda

Day 343, My time in Mseleni has been typified by the many adventures I’ve had, so it felt only right that I end with one. For the last six months, my lifelong ambition has been to see mountain gorillas in the wild, and a trip to Uganda with my friends proved my swansong adventure in Africa.

Expecting the oppressive heat I was pleasantly surprised by the cool evening landing in Kampala. Soon enough though we found out there was plenty else to be suffocated by other than heat. As we drove to our hotel our senses were bombarded. The smell of industrial smog permeated as we stood bumper to bumper with the din of traffic. Motorcycles buzzing around like flies carrying everything from bananas to families, cacophonous honking of truck horns, and the smell of fresh and cooking meat and vegetables accompanied us all the way.

The gorillas live in a mountainous area to the east of the country bordering Rwanda and the DRC. We took a 9 hour, dusty road trip to the region which included crossing over the Equator. A brief stop to confirm the Coriolis Effect and the science geek in me was satisfied.

Bwindi Impenetrable Forest is a fairly ominous sounding prospect for those at the peak of their physical prowess, so I was already tentative about my chances even before the trek began. A briefing from our guides on procedures and likely animal behaviours and we were allocated to the Mshiya family group, but this did not mean a guaranteed sighting, it all depended on the guile of the trackers and a little bit of luck.

The trek started through the outskirts of a mountain village. Ordinary people walked passed us as I already started to puff. By the time we reached start of the steep climb I was in trouble. Luckily the trackers ahead had radioed to let us know they had found the family on the other side of the hill, it just meant a further hour’s trekking at 2,000 feet and climbing. My friends were coping well but I convinced them to stop so I could rehydrate on more than one occasion.

Luckily conditions were perfect; the ground was dry, the air cool, and the gorillas unusually close by. Any other circumstances and I may not have had the energy to get to the top of the hill. It was mid morning when we met up with our trackers, we’d followed the path they had macheted and we stood with only a layer of dense foliage prevent us from seeing the animals. A little disappointed at first, we realised that the scouts were continuing to hack away the vegetation.

We snuck a quick glimpse, a face of a baby and what looked to be a Silverback. Still we waited trying to steal the odd glance, taking in the atmosphere of the moment. Once the animals were comfortable they ventured into the open. First it was the Silverback, sitting in the shade and munching away at shoots and leaves. Then we ventured further on to watch as the female climbed up a tree to have breakfast. Lastly it was the toddler, 3yrs old, swinging through the branches and gawping at the strange people and their little clicking machines. Mesmerised, we stood there for what felt much more than the allotted hour.

On the journey back down I was able to concentrate on the misty mountains and the vistas around me, and it began to dawn on me what a privilege it had been to be in their presence. Only a handful of people are allowed everyday and the arduous trekking is limited to those who are capable. With only 760 of them left in the world one hopes that the conservation efforts reap success.

For my part, this is the sort of experience that I would not have been brave enough to venture into in the past. But thanks to my adventures in Mseleni I have already begun plotting my other lifelong ambitions.

http://www.youtube.com/watch?v=d-ScbqH1Fz0

Day 335, End of Days

Day 335, The on call this week was my last call. Given that I will be returning to a job in general practice it was actually my last call ever. Sure, I may choose to work out of hours shifts, but as far as being an on call doctor it ended on a cold night in Kwazulu Natal. After the many exciting emergencies and soul destroying outcomes my last hurrah was not a bang but a whimper. I was allowed to sleep through most of the call with only mundane interruptions from the nursing staff.

In contrast to the call, my last full day on the wards at Mseleni was a reminder of why I may not miss this place much. We were short staffed and stretched pretty thin covering the OPD for large portions of the day. On the paediatric ward they decided to work me one final time; a 3 month old, desperately ill from pneumonia arresting at the same time as a 7 month old on the opposite side beginning to seize uncontrollably. One didn’t make it, the other survived, for now at least.

After the shocker of a day I returned to what I’ve recently known best, packing up. Sounds like it should be easy but it is remarkable what I’ve managed to accumulate in my time here. Sifting through the collection of odds and ends, I realised how my preconceptions about this place were so wrong; a pair of unopened shoelaces for shoes I ditched for being too impractical in the bush, a reel of thread to fasten mosquito netting I never required and a bike lock to secure my bags in case unscrupulous individuals lusted after them.

Like a snake shedding its skin I have been whittling away at my possessions to streamline my return home. My friends and colleagues are being lumbered with the oddest of gifts and they receive them in good humour, hopefully being able to put everything to use. Finding a suitable home for my belongings is no mean feat. The task is made more difficult mainly because whatever little time I have left is largely spent toasting my departure and I feel it would be a shame to spend it otherwise.

It is certainly more than just possessions that I will take with me and hopefully it will be more than just possessions that I leave behind. I don’t honestly know what I was expecting when I came here, but what I’ve encountered is far more than I could have bargained for.

http://www.youtube.com/watch?v=5WQU-yNzEek

Day 326, Beginning to Leave

Day 326, This evening I had my first farewell from Mseleni. Perhaps it is an odd thing to have a first farewell but I anticipate there will be several more before I actually leave. It has made me realise how the days are winding down and everything I do is potentially the last chance I will get to do it.

Last week was the last public holiday I would have in South Africa, and there has been an inordinate amount of these; Women’s Day, Workers Day, Human Rights Day, Freedom Day and last week’s Youth Day are in addition to the customary Easter/New Year’s and Christmas. This impromptu mid week break led to another last, a final beach day. The early darkness and cooler temperatures have meant fewer trips to the sea of late, and it was a welcome sunny day for a refreshing dip in the warm ocean one more time.

For others around me it is just another clinic or on call or day at the beach, but for me I’ve taken to savouring each event with as much gusto as when I first arrived. I have seen others who have left do the same and I’ve looked on thinking I would be more nonchalant, but alas I am not so different. It is not that I need to make everything special, nor is it that I am regretting leaving it all behind. It is more that this place has now become a part of me and I want to ensure it remains engrained in my mind.

I have moved many times in my life and I have never been completely at ease with it. Yet this time it feels different. I don’t think I will truly understand why for some time yet, but it is probably testament to my time here that I leave with a sense of trepidation. But I came here under the premise that anything worth doing must be scary and I leave with that in mind.

I will miss the crazy adventures, I will miss the improbability of medicine here, I will miss my friends, and I will miss waking up with the sun in my face. But for all the excitement of the final experiences what I will miss most is the also the reason that I must move on; the need to challenge myself.

Saying goodbye shouldn’t be a happy thing, and it is only easy when nothing has mattered. That’s why I am looking forward to multiple miserable farewells before I finally leave.

http://www.youtube.com/watch?v=nabO_UXb6MM

Day 324, White Patients

Day 324, A two tier health system isn’t exclusive to the developing world but the wealth gap just makes it more evident. South Africa’s past means that it isn’t only a wealth but also a race gap which prevails. So it is always interesting to see the dynamics when a white person rocks up at a rural district hospital.

There are broadly two types of white patients that may present; the first are out of towners holidaying in the region who happen to need to some medical attention that do not want the two hour drive to private care; the others are those that have fallen on hard times or Previously Advantaged, Now Disadvantaged (PANDAs). The latter will often come and wait in the OPD with all other patients while the former will insist on being seen immediately.

PANDAs will often be patients who aren’t able to afford medical insurance and will end up in a system that 20 years ago they would not have dreamed possible. We aim to treat everyone equally of course, whilst that is a step up for most Zulu patients compared to the past, for this population group it is a downgrade. It can understandably be frustrating to them and they will often get restless in the waiting room. Chronic illnesses are common in this group and occasionally we will even see a HIV positive white patient; it is slightly sad how they often will be at pains to explain how they contracted it through no fault of their own.

The frustrations for us medics tend to be the out of town patients who will demand instantaneous service such as in a resource rich environment. Our limited staffing means that patients are often left waiting for investigations or to be seen by a doctor, especially out of hours. However those used to private care aren’t always as appreciative of this as our regular population. Their agitation is often contagious to the nurses who will be at pains to point out that it is a white patient waiting, as if this can speed up the delivery of care.

One wonders whether the attitudes of both the white patients and Zulu nurses are a throwback to the institutionalised ideas of the Apartheid era. Perhaps it is simply that the reality of having well dressed white patients sitting in the same waiting room where malnourished babies and tuberculous adults are on death’s door is just socially unacceptable.

The problem with treating everyone equally is that not everyone feels they are equal to others. Some people will always see themselves as more privileged while others will continue to feel they are subordinates. With that in mind the only choice is whether to treat everyone with equal contempt, or equal kindness.

http://www.youtube.com/watch?v=THI4U3OsDQY